Health assessment Exam 1
Card Set Information
Health assessment Exam 1
244 exam 1
what is Subjective data gathered during the health assessment?
What client tells you
What is objective data gathered during health assessment?
Information gathered during physical exam
What are the purposes of a health history?
understand client, promote health and wellness, council about disease prevention, negotiate plan of care
What are 4 types of health history
Initial, interval/follow up, focused/problem oriented, emergency
What is involved in a history of present illness?
Onset, Precipitating factors and progression, Quality and quantity, Relieving and aggravating factors, Sequelae, Timing, Understanding
What are constitutional symptoms?
Unexplained fever, night sweats, weight loss or gain, change in appetite, fatigue
What are the ages for: childhood, adolescence, adulthood
Childhood - to 12
Adolescence - 12-18
Adulthood - 18+
What is a question that must be asked with every health assessment?
Any drug allergies
How do you find a tobacco use pack history?
packs/day x years smoking
When taking a family history how far back do you go?
If possible 3 generations - find out conditions, cause of death, current health
What are the techniques of physical assessment?
Observation/inspection, palpation, percussion, ascultation
What are the plexor and pleximeter?
Plexor - middle finger that strikes during percussion
Pleximeter - stationary finger that is struck
What pitches are the diaphragm and bell of the stethoscope used for?
Diaphragm - high pitched - breath and bowel, heart sounds
Bell - Bruits and cardiac murmurs
What are the layers of the skin?
Epidermis - superficial, avascular, melanocytes
Dermis - vascular CT with sebacious glands and some hair follicles
Subcutanious tissue - fatty cells, sweat glands
What is an apocrine gland?
a gland that opens into a hair follicle, produces an odorless secretion in response to emotional stimuli, causes body odor due to bacterial decomposition
What are three types of skin cancer?
basal cell, squamous cell, malignant
What are ABCDE of skin cancer
Asymmetry, border, color, diameter, evolution
What is carotine?
golden yellow skin pigment, exists in subcutanious fat and keratinized areas. Carotenemia is excessive carotene causing yellowness that does NOT involve conjunctivae or other mucous membranes
What is jaundice?
increased bilirubin levels causing yellowness in skin, conjunctivae, etc. Suggests liver disease or excessive hemolysis of RBC. Check under NATURAL light.
What is rubor?
increase in blood flow causing reddening.
What is pallor?
decrease in blood flow making patient pale.
What is cyanosis?
increased concentration of deoxyhemoglobin due to hypoxia causing blueness of skin.
What do you check for peripheral and central cyanosis?
Perepheral - nails, skin on extremeties
Central - BUCCAL MUCOSA, lips, tongue
What is diapheresis?
Where and how do you check for turgor?
check for tenting in sternoclavicular junction
What are striae?
stretch marks - silver or pink. Purple indicates possible Cushings
What is Vitiligo?
pigmentary disorder with loss of melanocytes. Chalk white, nonscaling, macular patches
What is a primary skin lesion?
A lesion that was not there before
What is a macule?
a flat, nonpalpable, circumscribed lesion under 1 cm eg. freckle, measle
What is a patch?
a flat, nonpalpable, circumscribed lesion over 1 cm e.g. vitiligo, stage 1 pressure ulcer
What is a papule?
an elevated, circumscribed, palpable, solid lesion under .5cm eg nevus, wart
What is a plaque?
elevated, circumscribed, palpable, solid over .5cm lesion. eg psoriasis
What is a nodule?
elevated, circumscribed, palpable, solid, .5cm - 2cm lesion, deeper and firmer than papule e.g. lipoma, cyst
What is a tumor?
elevated, circumscribed, palpable, solid over 2cm lesion e.g. carcinoma
What is a wheal?
a transient, irregular edematous variable sized lesion e.g insect bite/hive
What is a vesicle?
elevated, circumscribed, palpable, serious fluid filled lesion under 0.5cm e.g. herpes simplex, herpes zoster, chickenpox
What is a bulla?
elevated, circumscribed, palpable, serious fluid filled lesion over 0.5cm e.g. impetigo, large burn
What is a pustule?
vesicle or bulla that becomes pus filled e.g acne, impetigo, furuncles, carbuncles, folliculitus
What is a cyst?
encapsulated, fluid filled or semi-solid lesion in subcutanious tissue or dermis
What is a secondary skin lesion?
A lesion that results from a primary lesion
What are above and below skin surface secondary lesions?
above - scales, lichenification, crust, atrophy
below - erosion, fissure, ulcer, scar, keloid, excoriation
What are vascular abnormalities?
Petechae, hematoma, purpura
What is the scale for edema?
trace +1 - 2mm
Mild +2 - 4mm, 10-15 seconds response
Moderate +3 - 6mm, 1-2 minutes response
Severe +4 - 8mm, 2-5 minutes response
What is onychomycosis?
Fungal infection of nail, thickening, browning, crumbling, patching
What is clubbing of the nails?
caused by hypoxia, normal nail angle 160, early - 180, late - over 180. Do Schamroth technique to test
What is normal capillary refill for finger and toenails?
fingernails - under 3 sec
toenails - under 5 seconds
checks for perepheral oxygenation
What is acute pain?
It is short lived, has sympathetic system involvement (increased pulse and blood pressure)
What is chronic pain?
Long standing pain with adaptation of sympathetic nervous system
What are the three categories of chronic pain?
Persistant or recurring
What are harmful effects of unrelieved pain?
Endocrine - prolonged stress response
Cardiovascular - increased HR, O2 demand, BP, hypercoagulation
Respiratory - disfunction
GI - decreased motility
Musculoskeletal - muscle spasm or immobility
Cognitive - confusion
Immune - depressed immune response, enhanced tumor growth
Infection - decreased subcutaneous O2
Where do you assess strength and regularity of aortic pulsations?
Where does the trachea bifurcate?
at the angle of Louis
What rib is at the tip of the scapula?
What is the posterior equivilent of the Angle of Louis?
How is the right main bronchus different to the left?
wider, shorter, more vertical, more succeptable to aspiration
Where are the apices of the lungs located?
2-4 cm above 1st rib into base of neck
Where is the base of the lung located?
T10 posterior, 8th rib axillary, 4th rib anteriorly
Which lung lobe has 3 compartments?
Where are the most common symptoms of respiratory disfunction?
Dyspnea, cough, sputum production, chest pain
What are objective signs of dyspnea?
increased respiratory rate, nasal flairing, dusky mucosa, use of accessory muscles to breathe
How does respiration change with aging?
chest wall becomes more ridged, respiratory muscles weaken, shallower breathing, decrease in elastic recoil, alveoli less elastic, decreased cough reflex
What is the most important assessment?
What is the tripod position?
using arms to support weight and lift chest to increase breathing capacity
What is a barrel chest?
Occurs with COPD, chest appears in continuous inspiration, kyphosis, costal angle greater than 90 degrees
What is stridor??
an inspiratory wheeze that is heard in trachea
What are Cheyne-Stokes?
cyclic pattern of apnea and varied breathing in final stages of life.
What is Kussmaul's respiration?
Hyperpnea and hyperventalation - happens with DKA
What is crepitus?
a cracking sensation felt when palpating
What is tactile fremitus?
vibrations of air in bronchial tubes heard when patient says "99"
When would tactile fremadus be reduced?
When would tactile frematus be increased?
What is normal resonance when percussing thorax?
loud intensity, low pitch, long duration, hollow sounding
What would be indicated by hyperresonance when percussing thorax?
What would be indicated by dullness when percussing thorax?
what are normal tracheal breath sounds?
loud, high pitched, harsh, hollow. Inspiration = expiration
What are normal bronchiovesicular breath sounds?
Intermediate intensity and pitch
What are normal vesicular breath sounds?
soft, low pitched, breezy, swishy. Inspiration longer than expiration
What are 3 characteristics of crackles?
occur on inspiration, discontinuous, air through fluid
What are three characteristics of wheezes?
occur on expiration, continuous, air through bronchoconstriction with inflammation
What are fine crackles?
high pitched, discontinuous popping sounds at the end of inspiration
What are medium crackles?
lower more moist sounds heard mid inspiration
What are coarse crackles?
louder, lower pitched bubbly sounds through inspiration
What are sibilant wheezes?
prolonged high pitched, musical sound heard primarily on expiration
What are sonorous wheezes?
low pitched snoring or moaning sound heard primarily in expiration but can be throughout